for Mental Health Services
At a semiannual meeting of the Federal/National Partnership for Children's Mental Health on April 29, 1998, an exciting new interagency Cultural Competence Task Force was formed. The work of this Task Force is also supported by the Federal Interagency Coordinating Council.
Among several priorities and recommendations identified for the Cultural Competence Task Force at the April 29th meeting of the Federal/National Partnership for Children's Mental Health, there was enthusiastic consensus among participants to begin work on three tasks:
To develop a common interagency definition of cultural competence
To assess and plan cultural competence training of federal partners
To help disseminate information on cultural competence.
The first task of the Task Force is to develop a common interagency definition of cultural competence, to assess and plan cultural competence training of federal partners, and to help disseminate information on cultural competence. A common interagency definition will hopefully be broad enough to be embraced by many different federal agencies. At the same time, it should be functional and practical so that agencies can use it as a basis to create their own definitions, policy statements, and plans for implementing cultural competence. The development of a common interagency definition of cultural competence has also been supported by the Services Integration Committee of the Federal Interagency Coordinating Council (FICC), a group of over 30 federal agencies which is legislatively mandated by the Individuals with Disabilities Education Act, Public Law 94-142. The Council's mission is to provide support to states on the delivery of early intervention services.
In order to consider the different perspectives implied in cultural competence definitions used by various agencies, the Task Force will assemble the various definitions or policy statements on cultural competence currently used by FICC agencies. Once the definitions and statements are received, Task Force members will analyze and synthesize the information and propose a common definition for all agencies.
To familiarize website visitors with the Federal/National Partnership for Children's Mental Health, the meeting summary report from the Federal/National Partnership's April 28, 1998 meeting has been provided as a reference.
Meeting Summary Report
April 29, 1998
Gary De Carolis welcomed the participants. He gave a brief overview of the history and purpose of the Federal/National Partnership for Children's Mental Health. The group has been meeting for 4 years as an opportunity to share information about working with children with severe emotional disturbance (SED) and their families. The work of this group has generated new grants; facilitated Federal interagency cooperation, including funding across agencies for technical assistance (TA); and has received recognition by Vice President Al Gore.
Mr. De Carolis stated the purpose of this meeting was to discuss the activities of Federal agencies in cultural competence when serving children with SED. In addition, there will be a "dry run" of the testimony to the U.S. Congress on the "Comprehensive Community Mental Health Services for Children and Their Families Program."
Bernard S. Arons, M.D., Director, Center for Mental Health Services (CMHS), spoke next. He asked for participation in the Walk the Walk March scheduled for May 2 in Washington, D.C. The event is sponsored by several organizations and is intended to raise awareness of mental health issues among Americans. Dr. Arons mentioned two CMHS activities that relate to cultural competence.
The Child, Adolescent, and Family Branch (CAFB), CMHS; National Technical Assistance Center for Children's Mental Health; Washington Business Group on Health (WBGH); and Federation of Families for Children's Mental Health cosponsored a conference titled "Success in a Changing Health Care Environment: A National Academy for Developing Child Behavioral Health Care Providers of Color."
To increase interest and awareness in child psychiatry, CMHS provides stipends for minority medical students to work with child psychiatrists in clinical settings and to attend the American Academy of Child and Adolescent Psychiatry (AACAP) annual meeting.
Albert B. Hiat, Ph.D., Indian Health Service (IHS), spoke next. He stated that IHS is cosponsoring the meeting and mentioned some issues of concern to Native Americans.
Third-party payers do not always reimburse traditional Native American counselors who treat children with SED. Traditional counselors usually are not credentialed but have influence within the tribe.
The use of standardized tests to assess children from different cultural and economic backgrounds results in misleading assessments; culturally appropriate tests are needed.
Those undertaking program evaluations need to consider the diversity of both the provider and target populations when doing such evaluations.
Dry Run of the Public Policy
on Children's Mental Health
Ellen Kagen reviewed the planned public policy briefing for Congress scheduled for May 14.
The briefing is a collaborative effort of six organizations: AACAP, the American Psychiatric
Association, the Federation for Families for Children's Mental Health, the Georgetown
University Child Development Center, the National Mental Health Association, and WBGH.
Ms. Kagen gave a brief review of the Comprehensive Community Mental Health Services for Children and Their Families Program (referred to hereafter in this section as "the program").
Since 1992, $227 million have been allocated to this program to provide children and their families with appropriate services that are individualized, comprehensive, community based, and driven by the unique needs of each child and his or her family. The evaluation of the original 22 grant sites showed that children with SED, their families, and the communities in which they lived were benefiting from the program.
In 1996 CAFB launched a strategic plan to maximize the impact of the program and to move the lessons learned to a broader audience. The process brought together families and professionals. Committees for public policy, communications, links to business, and research were formed. The priority of the public policy committee is to convey the following information to Congress.
The Federal Government, through CMHS, is investing in communities and families.
The investment is helping children, families, and their communities.
The program is cost-effective.
Ms. Kagen thanked the members of the committee, Sandra Spencer and her family, Tom
McMillian, Martha Kaufman, Neal Mazer, M.D., Claudia Faigen, Deborah Stark, Joan Dodge,
Ph.D., Barbara Huff, Mary Crosby, Connie Dellmuth, Madeline Gallo, Sylvie Kelly, Ray Riley,
Julie Shroyer, Andrea Price, Hillary Wilson, and Rolando Santiago, Ph.D.
The congressional briefing will consist of presentations by Dr. Mazer, Mr. McMillian, Ms. M. Kaufman, and Ms. Spencer and a video presentation about the Spencer family. Other materials will be available, including a factsheet on the program, a glossary of terms and information on legislative opportunities, cosponsoring organizations, and systems of care. The meeting participants were encouraged to ask questions after the presentation that congressional representatives would ask and to critique the presentation. Dr. Mazer began the rehearsal with background information about children with SED.
Increasing numbers of children are experiencing emotional, behavioral, or developmental problems. CMHS estimates that 20 percent (13.7 million) of U.S. children have a diagnosable mental problem, and nearly one-third of those children (3 to 4 million) have severe emotional or behavioral problems. Approximately one-third of the children on Medicaid have SED.
Children who have SED, suffer from drug addiction, or commit suicide come from all sectors of society.
Forty-eight percent of children with SED drop out of school between grades 9 and 12. Eight percent of children with SED drop out before the 9th grade, and of those children with SED who do drop out, 73 percent are arrested within 5 years of leaving school.
Most communities lack appropriate treatment and services for children with SED.
The Comprehensive Community Mental Health Services for Children and Their Families
Program is a Federal initiative to integrate systems of care. The community-based program provides support to 31 communities in 21 States to develop and implement innovative ways to provide cost-effective, results-based mental health services for 23,000 children and their families. The program can be summarized with the "several Cs": connection, caring, competence, confidence, collaboration, communication, creativity, and community.
The program emphasizes cooperation among agencies within the community to provide individualized treatment for each child in their own home and community. The personnel who work together include public health nurses, families, psychologists, juvenile justice staff, and school personnel. Federal funds are used to retrain staff, increase family involvement, address family priorities, and develop new service technologies, such as respite and support programs and intensive in-home and in-school treatments. The program raises accountability by measuring outcomes and tracks programs to monitor effectiveness and costs.
Dr. Mazer presented the example of Shannon, who was diagnosed with either autism or a pervasive development disorder. His mother, Ms. Spencer, a single parent, was overwhelmed. By building on the strengths of the family, the nursing staff of the day treatment program where Shannon was a patient taught his mother the skills necessary to care for her son. Eventually, Ms. Spencer was employed in the day treatment program. Shannon has remained in school and has recently joined the ROTC (Reserve Officers Training Corps).
Using Federal funds, the program coordinates with existing community resources to provide a common approach that is new, more effective, and less duplicative and trains health care providers in the new approach. Evaluations have shown positive results. Examples follow.
School attendance increased 41 percent among chronically truant youth.
The number of youths rated by their parents as having SED and behavioral problems decreased 27 percent after 6 months in the program.
In San Mateo County, California, the number of crimes committed by youths in probation in the 12 months after entry into the program declined by 61 percent.
In Santa Barbara County, California, unemployment among mothers decreased by 23 percent after 1 year.
In the Wraparound Program in Milwaukee, Wisconsin, a child's average length of stay in residential placements decreased from 270 days to 112 days, a difference of 58 percent. The average monthly cost of caring for a child fell 37 percent, from $4,449 to $2,800.
In the ACCESS Program in Alexandria, Virginia, out-of-city residential placements decreased by 48 percent.
The program is creating new models of effectiveness that include (1) using strength-based approaches; (2) teaching hands-on practical skills; (3) involving important community resources, such as churches and schools; (4) using families as providers; and (5) empowering families and children to become an active part of their treatment.
A video presenting the story of the Spencer family of North Carolina was shown. Steven, a 5year-old boy, had been diagnosed with bipolar disorder and attention deficit disorder. He had mood swings, talked about not wanting to live, and had a history of running away. He was placed in a residential treatment facility, and his mother felt as if she had deserted her son. After a year in residential treatment, Steven was accepted into PENPAL, a community-based integrated program, and returned home. An interdisciplinary team, consisting of a psychiatrist, school counselor, therapist, teachers, his pastor, respite workers, child-care providers, and Steven's mother, now treats Stephen, and a service coordinator manages his care. The treatment builds on the strengths of the child and the family instead of concentrating on their weaknesses. Steven is now much improved.
Mr. McMillian, PENPAL services coordinator for Steven, presented next. Steven's mother, Ms. Spencer, was a single parent on welfare with two other children. Although Steven had SED, he was highly intelligent and affectionate, loved sports and animals, articulated feelings well, and responded positively to a supportive family environment. However, he could not control his oppositional behavior. The interdisciplinary treatment team identified and worked with Steven's and his family's strength and worked together to provide Steven and his family with the treatment to meet their unique needs.
Ms. M. Kaufman, State Administrator for PENPAL, spoke about the PENPAL program. In 1994 North Carolina received a CMHS grant to administer PENPAL in three rural counties. Previously, each county provided basic services for children with SED, such as juvenile justice, health care, mental health care, and the public school system. These services worked independently of each other, creating confusion for the family and duplication of services. PENPAL knits these services together, thereby decreasing duplication, and develops individualized service teams that include not only health care providers but also church workers, staff members from boys and girls clubs, and school personnel. The program supports families to become full partners in the child's treatment.
In addition, PENPAL facilitated new training for university students and teachers. East Carolina University trains many of the professional health care providers that work in local agencies. A training consortium organized by PENPAL integrated systems of care into the curriculums of nursing, therapy, social work, and the educational material of other service providers and implemented cross-agency training and student placement. PENPAL fosters a structure of community collaboration, drives systems of care in the community, monitors results, supports teamwork within the program, and is decreasing out-of-home placements. With CMHS funding, PENPAL is expanding throughout North Carolina.
Ms. Spencer, Steven's mother, worked with the PENPAL staff by reviewing new university curriculums, instructed in the collaborative training program, and became a full partner in treating her son. Eventually, she became a paid staff member and founded WECARE, an organization of families of children with SED and the local affiliate of the National Federation of Families for Children's Mental Health.
The meeting participants then asked several questions.
In response to a question about the need for Federal funds, Dr. Mazer stated that the current systems and the families are overwhelmed. Funds are needed for retraining staff and for implementing the wraparound approach.
In response to the question of when a child would need to be treated outside the home in a residential treatment facility, such as those in Minnesota, it was stated that at-home treatment is preferred but residential facilities can be used as a last resort.
The participants presented a short synopsis of their agency's activities that relate to cultural competence.
Tracy Chamblin, from the Family and Youth Services Bureau's National Clearinghouse on Families and Youth, stated that the clearinghouse links professionals, families, and policymakers; produces publications; and conducts research. In 1993 a working group on cultural competence conducted a literature review and interviewed representatives from 40 programs about cultural competence. The group learned that the major focus was on racial and ethnic issues, and they wanted to include other differences, such as sexual orientation, physical capacity, regional differences, new immigrant status, and gender. Based on their findings, the group produced the "Guide to Enhancing the Cultural Competence of Runaway and Homeless Youth Programs."
Theresa Sacchi, from the Technical Assistance Center for Traumatic Brain Injury, stated that this organization provides TA for the Maternal and Child Health Bureau's (MCHB) State Traumatic Brain Injury TA Program, which is a demonstration grant program active in 21 States. The grantees provide information about traumatic brain injury to diverse populations, and the center distributes information on brain injury in several languages to trauma centers and health care providers to help families from diverse backgrounds access appropriate care.
Mary Campbell, from the American Psychological Association (APA), related that their Office of Ethnic Minority Affairs has developed two publications on cultural competence, Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations and Visions in Transformations: The Final Report of the Commission on Ethnic Minority Recruitment, Retention, and Training in Psychology. The APA's task force for adolescent girls incorporates cultural competence and includes disabilities and gender issues.
Helen Kavanagh, from the Bureau of Primary Health Care (BPHC), stated that BPHC and the Division of Children with Special Healthcare Needs (both within the Health Resources and Services Administration [HRSA]) are funding a national center on cultural competence at Georgetown University. BPHC also has developed materials on cultural competence.
Bonnie Strickland, Ph.D., from MCHB, explained that the cultural competence center at Georgetown University provides TA, training, and develops self-assessment tools. MCHB also has discretionary initiatives to implement cultural competence in managed care systems and medical homes.
Jeanne DiLoreto, from the Substance Abuse and Mental Health Services Administration, (SAMHSA), works with the Starting Early, Starting Smart program. The program serves the Hispanic, African-American, Chinese immigrant, and Native American populations. A major study is planned that will use culturally competent study instruments.
Gail Ritchie, CMHS, stated that the center is collaborating with other agencies within the U.S. Department o f Health and Human Services to produce several publications on cultural competence. Topics include managed care, evaluation, a report card, and standards and guidelines.
Roxanne Kaufmann, who works in Early Intervention Policy at the Georgetown University Child Development Center, has worked with cultural competence issues in the Head Start program.
Roy Praschil, from the National Association of State Mental Health Program Directors, considers accountability, cultural competence, and family involvement to be the basic principles of their projects. The incoming president, Roy Wilson, will focus on cultural competence issues.
Marva Benjamin, from the National Technical Assistance Center, mentioned several activities, including the cultural competence training for trainers, the development of a cross-cultural definition of children's mental health, a guide for cultural competence in child abuse and neglect, and numerous monographs and articles.
Ms. Dellmuth, WBGH, provides technical assistance to CMHS grant sites that serve diverse populations. She noted one common problem: The majority of people served are people of color, but the health care personnel are not people of color.
Vivian Jackson, from the National Resource Network for Child Family Mental Health Services (NRN), is a coeditor of a book on cultural competence in managed mental health care.
Dr. Dodge, from the National Technical Assistance Center for Children's Mental Health, stated that the center provides TA for developing systems of care within Native American communities and within managed care groups and for operationalizing cultural competence in systems of care.
Michael Ambrose, from the Administration for Children, Youth, and Families (ACYF), is implementing the Multi-Ethnic Placement Act, which prohibits denial of adoption placement due to race or ethnicity. ACYF is seeking waivers of the foster care rules to allow Native American tribes to receive funds for their traditional form of foster care.
Moniquin Huggins, from ACYF, stated that her agency provides funding to assist families in accessing quality childcare and mental health care services and to improve service to diverse populations.
David Osher, Ph.D., from the Chesapeake Institute of American Institutes for Research, works with sites nationwide involved with cultural competence. The Institute has produced a handbook with a chapter on cultural competence, links members with groups knowledgeable in cultural competence, and supports workshops on cultural competence.
Trina Osher, from the Federation of Families for Children's Mental Health, stated that the federation believes that systems of care should be family-driven and cannot be culturally competent if they are not family-driven. The federation has an active diversity committee, works on issues of violence as related to poverty and race, and is producing a Spanish-language version of their Web site. Forty percent of the annual conference attendees come from diverse communities.
Anthony Sims, Ph.D., from the Center for Effective Collaboration and Practice, stated that the center links programs to research-based knowledge around diversity paradigms, such as identifying children with SED and addressing the disproportion of Hispanic and African-American children in special education. The center is compiling a database on cultural competence from the research perspective.
Clarice Leslie, CMHS, works on the public education campaign, Caring for Every Child's Mental Health, Communities Together. The materials developed use culturally competent visual aspects and languages and are pretested with appropriate focus groups. A culturally diverse list of media contacts was developed.
Charles Geboe, from the Bureau of Indian Affairs, stated that the Bureau operates 185 early childhood sites, schools, and colleges. The Bureau recently completed the Youth Risk Behavior Survey in high schools and middle schools, is integrating parents into early childhood education, and is testing new research-based curriculums.
Ms. Kagen, from Communities Can!, explained that the organization is a Federal collaborative that focuses on young children and their families and provides training and facilitation to communities on collaborative decision making. The organization's basic tenets include collaboration across agencies, inclusion of all, a belief that families are partners, and cultural competence.
Tom Hanley, from Special Education Programs, stated that this agency provides grants for model programs in cultural competence, works to improve special education programs, and works on gender and disability issues.
Cathy Girouard, from the Safe and Drug-Free Schools Program, reported that the program provides funds to States to set up prevention programs in schools for drug and alcohol abuse, violence, and hate crimes. The program requires a thorough needs assessment before designing the intervention.
Dr. Hiat stated that IHS is collaborating with SAMHSA to implement the Circles of Care program, which will develop systems of care in Native American communities. Project Making Medicine trains Native American providers to treat children who have been sexually and physically abused and includes Native American traditional care in its treatment regimen. In addition, IHS is developing child abuse prevention activities, assessing the health status of Native American children in foster care, sponsoring training for Native American social workers, and sponsoring the annual meeting of Native American psychologists.
Joye Whatley, from the Office of Victims of Crime, stated that her office funds victim services, supports training for diverse professionals who work with crime victims, develops projects to enhance victims' rights and services, and runs the State victims compensation program. Some States compensate crime victims for mental health care. The office also operates the community crisis response team that responded to the recent schools shootings in Arkansas and Kentucky.
Kevin Dwyer, from the National Association of School Psychologists, reported that the association has a multicultural committee that emphasizes the idea that systemic changes in behavior involve issues of awareness of, sensitivity to, and strengths of different cultures. The association established the National Mental Health and Education Center for Children and Families and will produce a publication that emphasizes that schools must change their educational delivery systems to reach diverse populations.
Gwen Freemen, from the National Head Start Association, mentioned that the association supports programs that place foster grandparents in Head Start classrooms and trains mental health care providers and Head Start personnel to integrate the revised Head Start performance guidelines.
Sharon Walter, from NRN, stated that the NRN provides TA on cultural competence in managed care.
Ms. R. Kaufmann emphasized that by 3 years of age children have formed opinions about themselves and others that perpetuate the cycle of racism and discrimination. A public awareness initiative is needed to break this cycle.
Breakout Session Discussion
The group divided into two facilitated groups for discussion and brainstorming. The breakout groups were asked to identify priorities and suggested next steps for the Federal/National Partnership group.
Dr. Sims reported for the first breakout group. Their priorities and suggested next steps follow.
Operationalize the definition of cultural competence as it relates to measurement and evaluation for projects that address cultural competence.
Develop and share evaluation tools.
Bring cultural competence to the community level. Use joint Federal dollars to fund parent organizations, particularly through use of cross-disciplinary and categorical funding streams to address cultural competence. Promote the mingling of funds at the community level.
Provide joint funding of community initiatives in leadership development to promote systemic change and facilitate cultural competence. Use the leadership activities of Communities Can!
Build leadership capacity in cultural competence, and use Communities Can! as one vehicle.
Ensure that each agency insists that every grant have inclusive review procedures and that they are enforced. Include cultural competence issues in every meeting. Do an internal self-assessment of how the agency prioritizes cultural competence.
Host an interagency meeting on cultural competence for grantees for the purposes of knowledge development and dissemination. Use the U.S. Surgeon General's conference or similar venues.
Develop a monograph on cultural competence that presents all the Federal agencies' efforts. Include lessons learned and strategic planning ideas.
Set up a joint cultural competence Web site for knowledge dissemination. Include hot links to appropriate Web sites.
Whatever priority is selected, the group should include cultural competence as an integral and basic component in all projects and policies, not merely as an "add-on" or a training event.
Ms. Benjamin reported for the second breakout group.
This group first considered some of the issues raised in the larger group meeting, such as the disproportionate representation of culturally diverse children and families in mental health services. The items mentioned that affect cultural competence included affirmative action and politics. The group considered both individuals and organizations. They stated that cultural competence is more than a model, consists of the attitudinal issues of exclusion and inclusion, and is not merely an external change and that a readiness is needed to accept the principles of cultural competence.
The second breakout group's priorities and suggested next steps follow.
Create a common definition of cultural competence. Begin with the existing definition and work with CAFB.
Realize that leadership must be challenged to change people's behavior.
Work with additional coalitions that are involved in cultural competence. Provide cultural competence training for the Federal/National Partnership group.
The breakout groups had these suggestions in common.
Develop a common definition of cultural competence for all Federal agencies, and disseminate the definition via a monograph or Web site material.
Do a self-assessment.
Provide training for the Federal/National Partnership group.
Comments from the group follow.
Several definitions of cultural competence exist; some are broad and general and can be adapted by other organizations.
Cultural competence is often confused with cultural sensitivity and cultural diversity.
Cultural competence is not addressed in Federal Government policy and needs to be explained to Federal legal experts, many of whom think it is similar to an anti-discrimination policy.
The definition developed should be measurable for evaluation and research purposes.
Develop a definition that can be operationalized in different areas by different agencies but that does not reflect language that serves as the lowest common denominator.
The following actions were suggested during group discussion.
A monograph on cultural competence will be postponed.
A committee was organized with Dr. Sims as chair. The committee will collect the existing definitions of cultural competence, develop a consensus on a definition based on the Georgetown definition, and present it to the group.
A cultural competence training for the Federal/National Partners, to be held at least in part in Washington, D.C., was discussed. The committee will identify existing training curriculums in the public and private sectors and will identify the desired outcomes of the training.
In addition, a great deal of information on cultural competence exists but more effective means of dissemination are needed. Suggestions include using the Integrated Service Committee of the Federal Interagency Coordinating Council, developing a Web site and listservs, requiring TA providers to compile resources as part of their grant agreement, and using channels other than published documents.
The group will meet again in 6 months. The participants were thanked for attending, and the meeting was adjourned.